Laserfiche WebLink
Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1. GenemtorlD Number 2. Page 1 of 3. Emergency Response Phone+ 4. Manifest Tracking Number Q <br /> WASTE MANIFEST "' C ® 1863538 5 JJ <br /> S. Gene Nto ae d a' in Ads , per � enemfots bite Address in different than mailing address) <br /> Genera sPhone:' <br /> 6. Transporter 1 Company Name _ U.S. EPA ID Number <br /> L r Z ��� <br /> 7. Tmnspoder2 Company Name <br /> U.S. EPA ID Number <br /> B. Designated acilly Nam and IteAddress U.S. EPA ID Number <br /> C RD <br /> Facil[lys h n : o' - E3�a ��'�' B � 0 06 <br /> ga, 9h. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 18. Containers 11. Total 12. Unit 13. Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity WLNoi. <br /> 'NON c A N K V5 VN � � Z <br /> z 2. <br /> C9 <br /> 3. <br /> 4. <br /> 14. Speclal Handling Instructions adAddilio ailnfonna6on J ` �' � <br /> PROFrICACn <br /> 15. GENERATOWSIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the propershipping name, and are classified, packaged, <br /> marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable International and national governments[ regulations. Ifexpodshipment and l am the Primary <br /> Exporter, I saintly that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. <br /> I codify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (ifI am a small 2VIy generator) is bue. <br /> Genembresl is 'ntedlfy me • ' rGignatur Moore Day <br /> 15 ,,11{{JJ�� l i m <br /> 16. International Shipments <br /> � ❑ Import fo U.S. ❑ Expodhom U.S. . Pod ofen(ry/exiC <br /> Transporter signature (for exports only): Date leaving U.S,: <br /> 17. TransporterAcknowledgment of Receipt of Materials <br /> SiLI <br /> TransporterlPrimadlfyped Name Signature Month Day Year <br /> O <br /> rw 13 <br /> 0 ra VC? <br /> QTransporter2Prl edffyped e NamS Month Day Year <br /> H <br /> 18. Discrepancy <br /> the, Discrepancy Indication Space ElQuantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> I Bb. Alternate Facility (or Generator) U.S. EPAID Number <br /> J <br /> U ' <br /> Facilitys Phone: <br /> w 18c. Signature ofAltemate Facility (or Generator) Month Day Year <br /> CDQ <br /> CD <br /> to. Hazardous Waste Report Management Method Codes (i.e., cedes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20. Designated Facility as Operator: Cedlficabn of mcq$1 of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedffyped Name Signature Mon Day Yr <br /> ea <br /> FPA Form 8700-22 (Rev. 3-05) Previous a Ions are obsolete. DESIGNATED FACiLI DESTENATI STATE (IIF REQUIRED) <br />